Strategies for Surgical Treatment and Outcomes in

Overview

Breast cancer is the most prevalent malignancy and the second most common cause of cancer-related death in women from North America and Western Europe. Skeletal involvement is commonly observed in women with metastatic breast cancer, with reported incidences ranging from 47 to 85% in autopsy studies and 69 to 80% when diagnosed through radiography.

Approximately one-third of these spinal metastases result in symptoms, which can include intractable pain, neurological deficits, and/or biomechanical instability, necessitating surgical intervention. The primary cancer’s histopathology has been demonstrated to have notable prognostic significance in patients with spinal metastatic tumors.

The treatment approach, radio sensitivity, chemo sensitivity, vascularity, growth pattern, and prognosis of the tumor can all be determined by the histopathology of the primary cancer. Despite being frequently asymptomatic, spinal metastases can lead to significant morbidity, pain, and neurological dysfunction, resulting in a negative impact on the patient’s quality of life.

An optimal approach to treating breast metastasis necessitates a multifaceted strategy involving medical treatment, radiotherapy, and surgery, among other treatments. A multidisciplinary approach is recommended. Systemic chemotherapy/hormonal therapy and spinal metastasis-specific medications, such as steroids, analgesics, and bisphosphonates, are among the medical treatments available.

Bisphosphonates are frequently utilized due to their high effectiveness in reducing bone pain, hypercalcemia, and pathological fractures. When systemic therapy and analgesics have failed to alleviate localized bone pain, external beam irradiation is typically the preferred treatment option and can often provide effective pain relief.

Spinal stereotactic radiosurgery (SRS) is a relatively new radiation therapy alternative for spinal metastases that may provide advantages over conventional XRT for treating metastatic spine disease. SRS has shown promising outcomes in terms of pain management and enhancement of neurological function in cases of metastatic spine disease.

Literature has shown that percutaneous vertebroplasty and kyphoplasty are safe and efficacious methods for treating refractory pain caused by pathological vertebral fractures resulting from metastatic spine disease.

Diagnosis of Spinal Metastasis

Diagnosing spinal metastasis involves a combination of imaging techniques and clinical evaluations. Common symptoms prompting further investigation include persistent back pain, neurological deficits, and sometimes, fractures due to weakened bones. Diagnostic steps typically include:

Imaging Studies:

1. • X-rays: Initially used to identify bone abnormalities.
   • MRI (Magnetic Resonance Imaging): Provides detailed images of the spinal cord and surrounding tissues, helping to identify the extent of tumor involvement.
   • CT (Computed Tomography) Scans: Offer cross-sectional images of the spine, useful in evaluating bone destruction and planning surgical interventions.
   • Bone Scans: Detect areas of high bone metabolism, indicating possible metastatic activity.

Biopsy:

• • A biopsy might be performed to confirm the diagnosis, where a tissue sample is taken from the affected vertebrae for pathological examination.

Indications For Surgery

Although the surgical indications for patients with metastatic spine disease from breast cancer remain a topic of debate, it is widely accepted that surgery is not intended to cure but rather to provide palliative care. If the patient’s overall medical condition is deemed suitable for the proposed operation and they do not have a limited life expectancy, surgery can provide significant benefits.

The decision to perform surgery for metastatic spine disease from breast cancer is determined by various factors, including the patient’s overall medical condition and life expectancy. Surgery may offer significant benefits if these factors are favorable. Indications for surgery may include:

• Worsening neurological deficits caused by bone or disc fragments in the spinal canal
• Biomechanical instability or deformity,
• Tumors that are resistant to radiation therapy or that continue to grow despite maximal radiation dosages
• Pain that is not manageable through medical interventions

Preserving or restoring neurological function is a key objective behind the promotion of surgical removal of spinal metastases in breast cancer patients. Patients with breast cancer are known to have longer life expectancies in comparison to those with other types of cancer. As a result, they should be considered as a subset that could benefit greatly from aggressive surgical intervention.

Surgery is also commonly used to address metastatic cancer pain that cannot be managed with medication and does not respond to radiotherapy. Literature has demonstrated that treating metastatic spinal lesions through vertebrectomy and stabilization leads to substantial and long-lasting improvements in pain management.

Regardless of whether the relief of pain is due to pain-relieving vertebrectomy, decompression, and/or stabilization, reducing pain and the use of narcotics (and the associated side effects) can have a significant positive impact on a patient’s quality of life.

After deciding which patients should receive surgery, the choice of surgical approach and technique must be determined. It is important to consider the anatomical location and the extent of the spinal disease.

Complications

Patients who are over 61 years old may be at a higher risk of experiencing complications during anterior spinal surgery. Experiencing blood loss exceeding 2,500 ml can increase the risk of complications. Prior to surgery, the use of radiotherapy may elevate the risk of wound infection and tissue breakdown, especially if the surgery is carried out using a posterior approach.

Surgical intervention for spinal metastases in breast cancer patients can greatly alleviate pain and effectively preserve neurological function in the short term, with a low rate of complications.

Outcomes and Prognosis

The prognosis for patients with spinal metastasis from breast cancer varies based on several factors, including the extent of the metastasis, the overall health of the patient, and the responsiveness of the cancer to treatments. Advances in systemic therapies and surgical techniques have improved outcomes significantly. Key factors influencing prognosis include:

• Extent of Neurological Deficits: Patients with severe neurological impairment at the time of diagnosis tend to have a poorer prognosis.
• Response to Systemic Therapy: Effective systemic treatment can control the primary cancer and reduce metastatic spread, improving survival rates.
• Overall Health and Comorbidities: Healthier patients without significant comorbidities generally fare better post-treatment.

Post-Treatment Rehabilitation

Rehabilitation plays a critical role in the recovery process. A multidisciplinary approach involving physiotherapists, occupational therapists, and rehabilitation specialists helps in:

• Improving Mobility: Customized exercise programs to strengthen muscles and improve balance.
• Pain Management: Techniques like physical therapy, acupuncture, and medications to manage chronic pain.
• Psychological Support: Counseling and support groups to help patients cope with the emotional and psychological impact of cancer and its treatments.

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